Allied Health Scientific and Technical Professionals Showcasing Innovation
Contents Patient Oriented Care Delivery
2
Establishment of Physiotherapy and Social Work Service Nelson Marlborough District Health Board By Debbie Hollebon, Clare Holmes, Alice Scranney & Tom Morton
6
Community Pharmacy Anticoagulation Monitoring Service Canterbury District Health Board By Kevin Taylor
8
Dietitians Single Point of Request Canterbury District Health Board By Sally Watson
10
A Vision of Shared Care Southern District Health Board By Annie Sutherland and Noelle Bennett
14
Extended Scope Practitioner Counties Manukau District Health Board By Corey Rosser
Service Focused
18
Straight Up - Young People Talk About Alcohol Project Whanganui District Health Board By Sacha Harwood and Melissa Wishart
20
Senior Chef - Cooking Classes for Older People Canterbury District Health Board By Sally Watson
24
Tracheostomy Review and Management Service Capital and Coast District Health Board By Kerry Huggins and Molly Kallesen
28
Occupational Therapy Role on the Acute Orthopaedic Ward Capital and Coast District Health Board By Jess Thompson
32
Enhanced Recovery After Surgery (ERAS) in Orthopaedics Taranaki District Health Board By Greg Sheffield
34
Pharmacist Prescriber Counties Manukau District Health Board By Gemma Stanbridge
36
Paediatric Multimedia Project Canterbury District Health Board By Kate Parker
Educational Focus
42
Allied Health Technical and Scientific Educator Capital and Coast District Health Board By Suzanne Stubbs
48
Sonography Training Counties Manukau District Health Board By Gemma Stanbridge
Directors of Allied Health, Scientific & Technical Professions ‘Showcasing Innovation’ The roles of AHS&T workforces are fundamental to delivering all clinical services across the health sector, both primary (community) and secondary (hospital) care and this website is where you can find out why. The Directors of Allied Health, Scientific and Technical (DAHs) have joined up with Waikato Institute of Technology (WINTEC) and Christchurch Polytechnic Institute of Technology (CPIT) to produce a dynamic collection of Allied Health, Scientific and Technical (AHS&T) innovations to be launched at the Allied Health, Scientific and Technical Conference in 2014.
In this magazine we showcase and share the exciting initiatives happening in the AHS&T world and beyond and with the help and imagination of the Students at WINTEC and CPIT, through the 2013 academic year, they have been brought to life through the many multi media applications available. This has been a great, joint opportunity for both the health sector (DHBs), the health professions (AHS&T), the tertiary sector (WINTEC and CPIT) and the potential upcoming workforce (students).
Acknowledgements
We thank and acknowledge each of the teams from District Health Boards (DHBs) that have contributed their initiatives for inclusion in this ‘allied health, scientific and technical professions showcasing innovation’ project. We thank them for giving time in their busy schedules, bringing their expertise and enthusiasm to this project. We also wish to thank and acknowledge the students and tutors, at the School of Media Arts, WINTEC and Creative Industries, CPIT for their significant contribution to the design and delivery of this project. It has been a great joint effort delivering an excellent and exciting finished product. Directors of Allied Health, April 2014
Acknowledgements
Capital & Coast District Health Board
Counties Manukau Health Counties Manukau District Health Board (CMDHB) was
Capital & Coast District Health Board has two distinct
established on 1 January 2001 under the provisions of
roles. The Directorate of Planning and Funding Service
the New Zealand Public Health & Disability Act 2000.
(P&F) is responsible for assessing the health needs of
CMDHB is responsible for the funding of health and
the people of the district, and contracting the most
disability services and for the provision of hospital and
appropriate services to meet those needs. Hospital
related services for the people of Counties Manukau
and Health Services (HHS) is responsible for providing
(Manukau City, and Franklin and Papakura Districts) as
secondary services via the hospital and community
set out in the DHB functions and objectives in the Act.
outreach programmes. CCDHB operates two hospitals – Wellington and Kenepuru and as well as the Kapiti Health Centre at Paraparaumu. There are also a number of community bases.
Nelson Marlborough District Health Board Nelson Marlborough DHB’s over-arching vision is
Canterbury District Health Board
‘Leading The Way to Health Conscious Families’. That means both providing a range of health services and
Canterbury District Health Board is the main planner
also encouraging us all to build and maintain healthy
and funder of health services in Canterbury; Canterbury
lifestyles. NMDHB’s Mission Statement - ”To work with
DHB is also a tertiary provider of hospital and specialist
the people of our community to promote, encourage
services – both for the Canterbury population and
and enable their health, wellbeing and independence”.
also for the populations of other DHBs where more specialised services are unavailable; We are a promoter of our population’s health and wellbeing; and the largest
Southern District Health Board
employer in the South Island, employing over 9,000
Southern DHB has a staff of approximately 4,500 and is
people across our services.
governed by a Board made up of both publicly elected and government appointed members. The Board is accountable to the Minister of Health. As a DHB, we are responsible for planning, funding and providing health and disability services to a population of over 304,268 located South of the Waitaki River. Our catchment area encompasses Invercargill City, Queenstown – Lakes District, Gore, rural Southland, Clutha, Central Otago, Maniototo, Waitaki District and Dunedin City.
Taranaki District Health Board
Wintec
Taranaki District Health Board is a Crown entity
Waikato Institute of Technology (Wintec) is one of New
responsible for the provision and funding of health and
Zealand’s largest technology institutes and is a leading
disability services in the region. The board governs all
provider of high quality, vocational and professional
Taranaki public hospitals, community services, including
education in the Waikato region. With three campuses
district nursing, health education and public health,
throughout the region Wintec has been serving the
such as health promotion and protection. It will soon
Waikato for over 80 years. The Wintec team have
be responsible for many private services, such as GPs,
provided invaluable support to the AHSTC Committee
private rest homes and other health service providers,
and conference.
who have previously contracted with a Government agency (HFA) for services.
Whanganui District Health Board
CPIT Christchurch Polytechnic Institute of Technology is an inspiring place that changes lives. We support and empower people to succeed because we know that
Our vision is to provide ‘Better health and
when an individual succeeds, the whole community
independence’ with our mission being ‘to improve
benefits. The CPIT experience is all about learning,
health and independence through a responsive and
respect, innovation, connection and success. When
integrated health system’. All Whanganui District Health
you engage with us, you contribute to our community
Board endeavours are be guided by the following set
and gain from the experience. We have some of the
of values: Co-operation, Social equality, Adaptability,
most talented teachers and staff, innovative business
Development, Integrity, Responsibility, and Respect.
collaborators and supportive community partners around. All are passionate about the role they play in our students’ success.
Patient Oriented Care Delivery
Establishment of Physiotherapy and Social Work Service Community Pharmacy Anticoagulation Monitoring Service Dietitians Single Point of Request A Vision of Shared Care Extended Scope Practitioner
1
Establishment of Physiotherapy and Social Work Service Within Nelson Hospital Emergency Department
Nelson Marlborough District Health Board Article by Debbie Hollebon, Clare Holmes, Alice Scranney & Tom Morton
N
elson Emergency Department (ED) serves a catchment of
would be delivered Monday to Friday between 8 am to 5 pm. However,
approximately 90,000 people in the Nelson and Tasman
over the pilot both weekend and public holiday working would be trialled.
Region. In 2011, a strategic meeting was held, to discuss future models of care to address the increasing demands
The project commenced in early 2012, with established key
at the interface between primary care and the emergency
performance indicators, robust data collection and an agreed
department. A number of potential solutions were proposed and
evaluation framework including both quantitative and qualitative data.
an immediate step forward was to consider how Allied Health team
During the 22 weeks of the pilot a total of 749 patients received allied
members could be placed within ED to better coordinate responses to
services, representing 57% physiotherapy and 43% social work; this
optimise the patient journeys.
represented approximately 7% of the ED presentations over the 22 weeks. Of the total contacts for the 749 patients, a further 332 follow
The Director of Allied Health and the Clinical Director of the Emergency
up appointments were made by social work. Further demographic
Department became the sponsors of the project and established
breakdown identified 56% of patients were female and 44% male; 9%
a working group between allied health, medical, nursing and key
identified as Maori and this is significant as in the Nelson region only
stakeholders to ensure a robust quality, safety and clinical
9% identify as Maori, as reported in the Statistics New Zealand 2006
governance framework.
Census. All age ranges were represented, however the over 65 year olds received the highest intervention rate, followed by 17 – 44 year old
A six month project to deliver both physiotherapy and social
age group and equally 0 – 16 and 45-64 year old groups.
work service was implemented with the aim that the Allied Health practitioners would work as part of the multi-disciplinary team, utilizing
In relation to physiotherapy, the majority of referrals were for musculo-
their unique knowledge and skills to assess patients physical, mobility,
skeletal injuries across all age ranges, with lower limb injuries and falls
rehabilitation, support, and psychosocial needs and advocate for
being the predominate presentation; primary contact intervention was
patients. Linkages to other allied health services and the coordination
provided to 120 patients.
of discharge planning back to the primary care sector would also be a focus.
Social work services related predominantly to the assessment and provision of home care support, followed by support to children and
Unique to the pilot was the establishment of primary physiotherapy
families experience a wide range of different needs such as financial
contact, which involved patients being identified, assessed and
assistance and domestic violence.
treated by the physiotherapist directly from the initial presentation and triage. Strict criteria applied and this related only to those patients
A consumer questionnaire indicated 86% of responders rated the
with musculo-skeletal conditions triaged at level 4 and 5. The service
service extremely helpful. Common themes included the benefits of
supported the Ministry of Health ED targets, to provide ‘Better More
receiving information, treatment, practical support, follow-up advice
Convenient Services’, and ensure the right service is delivered at the
and support into the community from the allied health staff. All ED staff
right time by the most appropriate health professional. The service
reported both social work and physiotherapy extremely helpful. The
2
common themes reported were the freeing of medical and nursing staff time to concentrate on triage 1, 2, 3 patients, the positive impact on the quality of patient care, support for young doctors, MDT working, assistance with new GP enrolments, screening for falls in over 65 year-olds, coordinated discharge planning, and addressing frequent presenters to ED. DHB and community stakeholder feedback reported improved communication across the hospital and community, admissions to hospital were avoided, families were more supported and empowered, there were positive linkages to private providers, a reduction in hospital based acute allied health staff being called to ED and the early identification of rehabilitation patients i.e. stroke. During the pilot it was identified that 66 patients avoided admission to hospital, which along with the primary contact physiotherapy resulted in the cost benefits exceeding the personnel costs associated with the pilot, providing the DHB with financial savings. These savings, along with the experience of care for the patients being enhanced, interventions targeted, nursing and medical staff time freed and patients connected to primary and community services clearly demonstrated that the pilot had achieved its objectives. Following the success of the pilot, the Executive Leadership of the DHB endorsed the continuation of the allied health
A physiotherapist offers advice to an injured woman who has come to the Emergency Department.
service in Nelson ED from December 2012. The following were the team that rolled out the Pilot: Hilary Exton, Director Allied Health; Tom Morton, ED Clinical Director; Jan Mitchell, ED Charge Nurse Manager; Deidre Crichton, Physiotherapy Team Leader; Social Work District Team Leader; Alice Scranney and Clare Holmes, Physiotherapists and Debbie Hollebon, Social Worker.
3 Part of the team that rolled out the pilot for this project.
Emergency Department physiotherapists and social worker
“
Allied Health practitioners would work as part of the multidisciplinary team, utilizing their unique knowledge and skills to assess patients physical, mobility, rehabilitation, support, and psychosocial needs and advocate for patients.
�
4
5 Head of Emergency Department
Anticoagulation Monitor. Taking a reading from the Anticoagulation Monitor (below).
6
Community Pharmacy Anticoagulation Monitoring Service A Multi-disciplinary Approach Canterbury District Health Board Article by Kevin Taylor
T
he Community Pharmacy Anticoagulation
Pharmacy and the Laboratory. The results would then be
Monitoring Service (CPAMS) programme is
checked to ensure they matched.
not unique to Canterbury as it is a nationwide initiative, however the collaboration between the
Following the initial set up of the quality control process at
Canterbury DHB Planning and Funding department,
the Pharmacies, as with the GP clinic service, an evaluation
Pharmacies and Canterbury Health Laboratories (CHL) is. All
of the process was carried out. The results of the evaluation
three services are working collaboratively to ensure accurate
showed that the service was working well. The ongoing
results for enhanced patient safety through a rigorous
performance of the Pharmacies is continually monitored
quality control system. This includes regular comparisons
using this process.
between results being obtained in the pharmacies and those obtained in the laboratory, participation in an Australasian
The CPAMS programme is more sustainable as the
wide external quality control programme and continual
appropriate support networks are in place locally to
competency assessment of staff.
ensure ongoing training and competency of the staff at the Pharmacies and, therefore, ensuring the key goal of
Canterbury Health Laboratories has vast experience in point
patient safety.
of care (POC) international normalised ratio (INR) monitoring through implementation of a community warfarin monitoring
The benefits to the patients who require warfarin is that
service within rural and urban GP clinics. Canterbury Health
the testing required is now much less intrusive, it is now a
Laboratories has a passion for quality and patient safety and
simple finger prick test with results available immediately,
identified some scope to support community pharmacies
rather than a blood test (venesection in the arm) with results
with additional training and quality assurance not in place
taking approximately six hours. With this enhanced access
for the national initiative.
to warfarin monitoring it enables the accurate timely dosage of medication to be provided to patients.
Canterbury DHB Planning and Funding department and CHL worked collaboratively to develop a workable system for
The cost of testing itself is slightly higher than traditional
enhanced quality control, in line with the current protocols
methods but the time savings following up patient results for
in use at the GP clinics. New solutions were implemented
nursing and medical staff are substantial. Improvement of
to meet the unique situation of the Pharmacies. As blood
patient Warfarin levels within therapeutic range results is a
testing was a new service for the Pharmacies, to check
direct saving to the health system through reduced Emergency
the accuracy of the test results being provided by them, a
Department admissions from bleeding and clotting events in
mobile phlebotomist from CHL would visit to take blood
patients whose warfarin dose control is not maintained.
from patients and have the blood tested by both the
7
Dietitians Single Point of Request Canterbury District Health Board Article by Sally Watson
A
s part of the Canterbury District Health Boards
In mid-2012 a single point of request (SPOR) was developed
“whole of system” improvement initiative dietitians
with HealthPathways, a web-based patient management
in Canterbury have developed a new simplified
system, and the DSP.
process for general practice to request
This included:
publicly funded dietitian services. The previous
1. DSP jointly agreeing criteria and wait times;
process involved general practice sending requests to
2. establishing a simplified request process; and
individual dietitian service providers (DSPs). This process
3. a new pathway outlining access criteria, exclusions,
was confusing and complicated for general practice and
request process and wait times.
inefficient for DSPs. Considerable time was being spent by each DSP returning requests to general practice and/
At the end of 2012 the Dietitians SPOR was launched on
or re-directing requests to other DSPs. General practice
HealthPathways and promoted to general practice.
had to decide between ten different DSPs, each with their own access criteria and request process. The majority of
The new process includes the following significant changes:
access criteria were incomplete and/or ambiguous. To send
• A new pathway outlining access criteria, exclusions,
a request via the Electronic Request Management System
request process and wait times on HealthPathways.
(ERMS) was not an option at this point.
• Option to send requests via the ERMS or fax. A simplified faxed request form covering both adult and paediatric requests is available on the pathway. • Requests triaged by a dietitian against clear access criteria. Accepted requests are sent to the appropriate DSP. Declined requests are returned to the general
8
practice with reason for decline and the next best
an increased profile of dietitian services and access
option for the patient. This is usually to consider referral
criteria. Informal feedback from general practice has
to a private dietitian and/or community nutrition and
also been positive. Formal feedback will be sought after
physical activity programmes.
12 months of operation.
• The pathway includes a list of exclusions which are linked to relevant management pathways,
Request data at the Dietitians SPOR is collated into
written patient information and contact details for
quarterly reports and enables unmet need across dietetic
private DSPs.
services in Canterbury to be identified and quantified.
• A new email address, specifically for general practice
Currently the largest unmet need for both adults and
was set up to direct enquiries about access criteria,
children is dietary advice for weight loss. To address
exclusions and the request process.
unmet need the Canterbury District Health Board is supporting a whole of system approach to reviewing
In August 2013 feedback on the new process was sought
dietitian services which will be undertaken in 2014.
from DSPs. Feedback was very positive and benefits reported included an improvement in quality of requests, reduced dietetic time triaging and declining requests, plus
9
A Vision of Shared Care Radiation Therapist-Led Patient On-Treatment Review Clinics for the Management of Radiation-Induced Toxicities Southern District Health Board Article by Annie Sutherland and Noelle Bennett
A
s radiation therapy techniques become increasingly
most extreme but nonetheless fairly common toxicity,
complex and practice focuses on the greater good
severely affects patient comfort levels as well as their
of the patient, some crossing of professional
psychological well-being. It also poses the risk of infection
boundaries will occur. In a first for New Zealand,
in patients who, due to their condition and treatment, are
we instigated radiation therapist (RT) led on-treatment
immuno-compromised. In extreme cases extensive moist
review clinics for breast cancer patients which saw us step
desquamation may result in a treatment break, which could
into an area that is traditionally considered the domain of
compromise local control and, ultimately, patient outcome.
medics. Following on from this came clinical trials, initiated and managed by RTs, aimed at providing the authentication
Our overarching aim therefore has been to investigate
for our emerging evidence-based practice.
whether we could find a treatment that would be superior
One set of trials in particular had significant ramifications for
to the current “standard” of aqueous cream in that it would
our practice.
actually reduce the incidence and extent of radiation induced moist desquamation in breast cancer patients.
Breast cancer is the most common malignancy for women in New Zealand and the majority will receive radiation
We began our quest by running two successive clinical
therapy as part of their treatment regimen. Despite the
trials – the first one in Dunedin alone followed by a second
fact that severe acute radiation-induced skin toxicities will
multicentre one across four of the eight departments in New
occur in a significant proportion of patients (men get breast
Zealand (including Dunedin). These randomised controlled
cancer too!) there is no evidence-based standard treatment
trials compared the efficacy of a silicon foam dressing
for these reactions – in fact treatments aimed at trying to
(Mepilex Lite) with the standard treatment of aqueous cream
reduce these toxicities can vary not only between but also
on the severity of acute radiation-induced skin reactions.
within institutions worldwide.
Mepilex Lite is an absorbent, self-adhesive dressing consisting of a thin flexible sheet of absorbent hydrophilic
Treatment tends to be based on historical and anecdotal
polyurethane foam bonded to a water vapour-permeable
evidence with many departments – including ours – opting
polyurethane film backing layer. The contact surface of the
for the use of aqueous cream in spite of a large randomised
dressing is coated with a soft silicone adhesive layer without
controlled clinical trial (n=357) showing that aqueous cream
any added chemicals, based on the patented Safetac
neither prevents nor decreases the severity of skin reactions.
technology. It adheres to healthy skin thus keeping the
Radiation-induced moist desquamation (MD), the
dressing in position but does not cause trauma on removal.
10
Creaters of the project, Annie Sutherland and Noelle Bennett.
The material does not react with chemicals in or on the
very small bolus effect, generally they had to be removed
skin, does not react with radiation, does not stick to open
before radiation treatment was given because they covered
wounds and can be left on the skin for several days.
up the tattoos that are required for daily patient set-up.
A total of 104 patients were enrolled across the two trials,
Secondly, the dressings did not stick well around compound
each receiving 50Gy in 25 fractions or biologically
curves – such “awkward” places as underneath the breast
equivalent dose.
(inframammary fold) or in the axilla – the very areas that were prime candidates for developing moist desquamation. Whilst
Toxicities were assessed three times a week using the
the results were generally pleasing they did indicate that
Radiation-Induced Skin Reaction Scale (RISRAS) with
the incidence of moist desquamation was not significantly reduced (47% in the
patients doubling as their own controls to eliminate confounding
“Importantly from our perspective, the
axilla, 67% in the infra-
patient and treatment related
Film conforms to compound curves
mammary fold).
factors. The dressings were applied only after the first skin reactions,
thus potentially offering the ultimate in
We determined that we
in the form of faint erythema, were
protection to the infra-mammary fold and
wanted to succeed in
noted. The trial endpoint was moist
axilla – in fact patients have commented
decreasing the extent
desquamation (MD). The radiation dose received by the Mepilex and aqueous cream treated skin areas
that the Film is so comfortable they forget it is there.”
of moist desquamation in the axilla and the inframammary fold by 20% or more from the
was measured using thermoluminescence dosimeters (TLDs) in order to verify that
level the previous trials had shown. As radiation-induced
any difference in reaction between the two areas was not
skin reactions are so common in this patient cohort, from a
attributable to dose differences.
purely philanthropic standpoint any new treatment option that has the potential to minimise further distress to women
Statistical analysis clearly demonstrated a significant
during such a traumatic time in their lives has to be worth
toxicity decrease (42%; p<0.001). We hypothesised that
pursuing. We believed that If we could achieve this reduction
Mepilex Lite dressings reduced skin reactions by preventing
and validate the data we might then be in a position to
additional mechanical damage (due to friction between
suggest that our solution be used as standard protocol in
damaged skin and clothing or other body parts) and
NZ to prevent radiation induced skin reactions.
chemical injury (due to perspiration trapped in the basal layer) of skin that had already been sublethally damaged by
And globally? Well, there may also be huge implications
radiation, thus allowing for the repair of fragile skin rather
for adopting this same protocol worldwide as it could
than exacerbation of the damage. There were limitations,
positively affect the well-being of hundreds, possibly
however. Firstly, the dressings are not transparent, so
thousands, of women undergoing radiation therapy for
even though we had shown that the dressings had only a
breast cancer each year.
11
The results from this trial (which have been submitted for publication) have exceeded all our expectations, showing a reduction in the severity of skin reactions in excess of 90%. The most significant outcome, however, was that the incidence of moist desquamation. In these patients this With this in mind we started a new clinical trial in late 2012
was 0% which was stunning. For many breast patients
this time using Mepitel Film – a product based on the
moist desquamation is the norm; something to be accepted
same Safetac technology as Mepilex Lite. It is a very thin,
and put up with. The implications of these findings for our
transparent, fully breathable, elastic polyurethane film with
practice are huge. We have found that we can indeed fulfil
a much smaller bolus effect than Mepilex Lite (0.12mm
our overarching aim of finding a treatment that would be
as opposed to 0.5mm). Radiation treatment can be given
superior to the current “standard” of aqueous cream in
through the dressings and skin reactions easily assessed
that it would actually reduce the incidence and extent of
without removing it. Importantly from our perspective, the
radiation-induced moist desquamation in breast cancer
Film conforms to compound curves thus potentially offering
patients. As mentioned earlier, at this point in time radiation
the ultimate in protection to the infra-mammary fold and
induced skin reactions are incredibly common in this patient
axilla – in fact patients have commented that the Film is
cohort. From a patient standpoint, they can be irritating at
so comfortable they forget it is there. This time we wanted
best and seriously debilitating at worst so from a purely
to test the effect of the Film (against aqueous cream)
philanthropic standpoint any new treatment option that has
prophylactically, in other words by using it from the TLDs in
the potential to minimise further distress to women at such a
situ during treatment start of radiation treatment rather than
traumatic time in their lives has to be worth pursuing.
waiting until a reaction in the form of erythema developed. The treated area was to be divided into a medial half and
We have clearly demonstrated that our patients do not
a lateral half (containing the axilla) which would then be
need to suffer as a result of their treatment. An initial, and
randomised to Film (trial area) or cream (control).
admittedly very rudimentary, cost benefit exercise also indicates that achieving these outcomes does not have to be
It was our intention to test the dressings on a cohort of 20
costly – in fact there is the potential for substantial financial
post-mastectomy patients and 20 patients who had not
savings to be made if we can stop this patient cohort from
had a mastectomy thus allowing us to test the Film in the
developing these reactions in the first place. At last we have
infra-mammary fold and the axilla. Apart from this, we would
the evidence and knowledge that we need for patient care to
closely follow the protocol of our previous two trials to allow
keep pace with the technological advances that have seen
direct comparisons – ie: using the same treatment dose, the
treatment modalities change so radically for the better.
same skin assessment regime and measuring the radiation dose to the skin under all dressings using TLDs. As it turned out, recruitment to the trial was extremely brisk. Patients heard about the trial from other patients who told them how positive an experience taking part was, so new patients would arrive and request to take part! Consequently, we increased the trial numbers from 40 patients to a total of 80 (with ethics’ approval) and still managed to recruit 80 participants and complete the trial inside six months.
12
Radiography machine
13 Radiologists at Dunedin Hospital
Extended Scope Practioner Counties Manukau District Health Board Article by Corey Rosser
T
he goal is simple, reduce waiting lists for those
“The benefits of introducing these roles is manifold. DHB’s
struggling with back pain, and everyone is
are analysed every quarter to review their performance
happy. However, achieving that is the hard part.
against Ministry of Health targets.
Nevertheless, Counties Manukau District Health
Board’s implementation of the Extended Scope Practitioner
To provide increased access to elective services, Consultant
(ESP) role is making some inroads into reducing patient
surgical time needs to be freed up and using physiotherapy
waiting times.
skills provides an alternative but highly skilled and appropriate pathway for patients to access a specialist
The ESP role was first developed in 1987 at Bristol
orthopaedic opinion.
Southmead Hospital in the United Kingdom where it was driven by initiatives to reduce waiting lists, as well
It also increases throughput of patients, decreasing or
as modernisation of medical careers. The role allows for
maintaining outpatient waiting times. It improves working/
physiotherapist-led back clinics to initially assess benign
communication across specialities offering improved
musculoskeletal back pain patients referred by GP’s for
access for GPs.
orthopaedic opinion. From the surgeons perspective it is enhanced teamwork Studies have indicated that physiotherapists working in ESP
in the management of Orthopaedic patients with improved
roles or in First Specialty Assessor (FSA) led clinic roles are
multidisciplinary working.
effective in reducing orthopaedic waiting lists by managing non-urgent and non-complex cases as first-line practitioners.
Developing these roles also provides a pathway for retention
Research also identifies that very often an ESP can manage
of highly skilled senior physiotherapy clinicians, increased
an entire episode of patient care with accountability to the
liaison with orthopaedic department and increased profile of
lead consultant in that department. As the workload on the
physiotherapy department/expertise within the hospital”
surgeon decreases it allows them to undertake more efficient
From a patients perspective they have an early access to
case-loads and surgical interventions.
specialist skills.”
Counties Manukau District Health Board Senior
Physiotherapy-led back clinics were initially introduced
Physiotherapist Leena Naik explains the significance of the
in Counties Manukau DHB in 2007. The current FSA
ESP and FSA roles to physiotherapy.
role was established in response to a 2012-2013 MOH strategy to improve access to elective surgery, whereby the
14
physiotherapist, as a First Specialty Assessor (FSA), can free up surgeon time to tackle elective surgery lists and reduce waiting times within orthopaedic outpatient clinics. Within Counties following introduction of these FSA led clinic there was a drop in average wait times from 140 to 123 days. However this is dependent on many variables such as referral patterns. At Counties the wait times for Physiotherapy led clinics is on average 90 days. “If you look at back pain as such, which is what the clinic is more or less about, probably 80 percent of back pain patients can selfmanage their conditions. “There is probably 1-2 percent who undergo a surgical intervention and 10 percent of patients who actually have any kind of what we call ‘red flags’ or cancerous tumours or infections.”
Senior Physiotherapist Leena Naik
15
Service Focused Straight Up - Young People Talk About Alcohol Project Senior Chef - Cooking Classes for Older People Tracheostomy Review and Management Service Occupational Therapy Role on the Acute Orthopaedic Ward Enhanced Recovery After Surgery (ERAS) in Orthopaedics Pharmacist Prescriber Paediatric Multimedia Project
17
Straight Up Young People Talk About Alcohol Project Whanganui District Health Board Article by Sacha Harwood and Melissa Wishart
A
“shoestring” Whanganui DHB project that aimed at
to resources to support curriculum delivery particularly
giving teenagers informed options and strategies
New Zealand resources. A previous Ease Up on the Drink
around alcohol, actively engaged young people in
initiative delivered in the schools also supported a New
the conception, development and delivery stages
Zealand resource as being more likely to engage students
of the project.
when discussing alcohol.
The Straight Up project developed a teaching resource to
“Ninety five young people were engaged in the project, even
be used in Whanganui secondary schools and alternative
gaining NCEA level 2 credits for their involvement. They
education providers. This was designed to raise youth
interviewed people from the different professions and across
awareness and understanding around alcohol-related harm
the community sector, plus tertiary students from UCOL
and harm minimisation.
(Universal College of Learning) did filming to develop a DVD as part of the teaching resource for schools.”
Mark Wood, Clinical Manager for Child and Adult Mental Health Services says alcohol can be really damaging to
Six posters were produced from the ‘attitude’ segments of
young people, “Young people didn’t seem to understand
the DVD, these were the key messages the young people
they were placing themselves at huge risk. They just didn’t
wanted to share.
have strategies for keeping themselves safe. Yet after viewing the DVD, students had up to 100% increase in
‘Don’t compromise yourself, e hoa ma, you’re all you got.’
knowledge around at risk drinking and keeping themselves
‘Sex is a huge step, don’t let alcohol influence that.’
and their mates safe.”
‘Advertising makes drinking look a lot cooler than it actually is.’
The project is a result of two developments in the
‘You don’t have to get wasted to have a good night.’
community and along with the young people a number
‘Kaua e tukuna ma te waipiro e tukituki ou taonga tuku iho –
of professions within the health sector and across the
Don’t let alcohol destroy your inherited talents.’
community sector were involved. These included the Public
‘He was going on about how smashed he got ... Bro that
Health Centre, Alcohol and Other Drug Services, public
aint cool, that don’t impress me.’
health nurses, teachers and a GP. Those involved from the emergencies services were from the hospital emergency
The young people came up with a whole lot of questions
department, NZ Fire Service, St John Ambulance
they wanted to ask related to alcohol and drinking. Some
and Police.
of it was about confidentiality; some of it was about how the services respond and some of it was about what the
The Public Health Centre in Whanganui conducted
services thought around alcohol. For example, they asked
an alcohol and other drugs needs analysis survey to
Police staff, “If a young person was found drunk and
understand the issues schools were facing. Schools
the Police turned up, what would happen?” They asked
participating in the survey identified a need for access
hospital emergency department (ED) staff, “When someone
18
who is drunk ends up in ED, do they have their stomach pumped?” “Even them just thinking about the kind of stuff they wanted to talk about, for us, was huge. It’s about a change in attitude, we’ve got to change the way they look at it.” Mark says there is no point in going on at teens not to drink; rather the project was aimed at informing teens and giving them options and the knowledge to make the right decisions when or if they choose to drink. On what Mark describes as a “tiny, shoestring of a budget” the project was able to incorporate many different angles and views for young people to think about in relation to alcohol. “There was a clear message that young people can make a different choice.”
19 Mark Wood, Clinical Manager for Child and Adult Mental Health Services
Elderly citizens in a Senior Chef cooking class
20
Senior Chef Cooking Classes for Older People Canterbury District Health Board Article by Sally Watson
S
enior Chef is a free eight week cooking course which
confidence to cook, cooking skills, fruit and vegetable, milk and milk
provides older people with an opportunity to improve their
product intake and social behaviours higher post course.
nutrition knowledge, cooking skills and to also share meals and socialise in a group setting.
Follow-up evaluation showed these improvements were maintained a year after completion of the course. In addition to quantitative
In 2007/08 dietitians from the Healthy Eating, Healthy Ageing project
evaluation, overwhelming positive feedback from participants was
at the Canterbury District Health Board conducted research on the
received. Common themes included having fun, learning new skills
prevalence of nutrition risk among community-living older people.
and knowledge, increased confidence and enjoyment of socialising.
A sample of 152 people were recruited from medical and falls
The following comment from a 71 year old man was typical. “After
prevention services in Christchurch. As classified by a validated
52 years of having my meals prepared and presented to me by my
nutrition risk screening questionnaire, 31% were found to be at
wife, I suddenly found myself faced with a dilemma that I had not
high risk of poor nutrition. Eating alone and difficulty cooking were
anticipated. Thanks to this course, I now feel that I will be able to
among the common risk factors placing those at risk. To address
look after my nutritional needs with confidence. I hope that those in
these findings, the project dietitians, with funding from the Ministry of
authority will see the enormous benefit of these courses and ensure
Health, developed ‘Senior Chef’.
that they are continued.”
Senior Chef is suitable for older people aged 65 and over (55 and over
Since it was launched, 95 courses have been delivered in Canterbury
for Maori and Pacific people) who live alone or with one other person and
with 940 people graduating from the course. The project dietitians
want to improve their skills, motivation or confidence around cooking.
support graduates to maintain their interest in cooking, eating well
Classes are three hours long and run once a week, starting at 10 am.
and socialising with others by organising regular social events, a
There are usually 10 participants in a course. Each weekly class includes
quarterly newsletter and a Senior Chef website (www.seniorchef.co.nz).
nutrition education, preparing and cooking a meal in pairs, followed by
The website includes information about the course, regional on-line
eating the meal as a group. The nutrition education component covers
enrolment forms, nutrition articles and an extensive recipe section. It
topics relevant to older people and includes eating well, menu planning,
also, includes a members only area for Senior Chef facilitators.
budgeting and shopping tips. The ‘Cooking for Older People’ recipe book, developed by the project dietitians, is used as the main resource.
Due to the success of the courses in Canterbury, Senior Chef has been
It contains easy, healthy recipes that serve one or two people. The
adopted in other regions and to date is available in Southland, Otago,
course is delivered by trained Senior Chef facilitators.
South Canterbury, Marlborough, West Coast, Hawkes Bay and Auckland. Senior Chef is now well established and the positive health outcomes
After two pilot courses in 2009 showed positive outcomes, Senior
demonstrated in Canterbury shows it is an important community based
Chef was launched in Canterbury in early 2010. Formal evaluation
initiative which can contribute to keeping older New Zealanders healthy
of the first 100 participants attending Senior Chef showed positive
and living in their own homes for as long as possible.
health outcomes. Participants rated their food and nutrition knowledge,
21
Elderly citizens in a Senior Chef cooking class
22
23
Tracheostomy Review and Management Service Capital and Coast District Health Board Article by Kerry Huggins and Molly Kallesen
T
he Tracheostomy Review and Management
in process and some concerning examples of poor
Service (TRAMS) is an interdisciplinary
tracheostomy management which created significant risk for
team that provides advice and management
patients. In addition, the team became aware of deaths in
for hospital patients with percutaneous
the region due to tracheostomy mismanagement and were
tracheostomy tubes after they have left the
keen to prevent this at CCDHB. In addition, the TRAMS
Intensive Care Unit (ICU). The team includes speech-
project group conducted a survey of doctors, nurses and
language therapists (SLT), physiotherapists, nursing and
allied health professionals across the hospital.
intensivists. Each team member contributes to decisions around the weaning and removal of tracheostomy tubes
Results indicated that most staff saw very few patients with
(referred to as decannulation).
tracheostomy (one or fewer per year) and many staff expressed low confidence in managing patients with tracheostomy.
In 2008, a Speech Language Therapist attended a workshop at the New Zealand Speech-Language Therapy Association
The TRAMS project group felt patients with tracheostomy
conference in Auckland by an SLT, physiotherapist
would receive a much better and safer service if there were an
and nurse from the TRAMS service at Austin Health in
interdisciplinary service to provide education and support to
Melbourne, Australia. Austin Health was the first hospital
nurses caring for patients with tracheostomies; a very similar
to develop and document an interdisciplinary model to
model to Austin Health. The CCDHB approach is unique
maximise safety and education regarding tracheostomy
because it is led by the ICU team. This means that the same
management. This proactive approach resonated with the
doctors who insert the tracheostomy follow the patient and
SLT and her Allied Health colleagues as they had often
manage the tracheostomy until it is eventual removal.
been frustrated by delayed and risky decision making regarding ward tracheostomies and the lack of delineation of
The project group collaborated closely with ICU staff, ward
responsibility, which led to increased risk to the patient and
staff and allied health to develop the Tracheostomy Review
cost of care. The C&CDHB SLT approached ICU to see if
and Management Service (TRAMS) Policy. The TRAMS
such a model would be possible at our hospital. In 2009, an
team was officially launched in April 2011. Since then, every
ICU intensivist, nurse and SLT visited TRAMS in Melbourne
patient with a percutaneous tracheostomy discharged from
in 2009. This visit energised the team and was the catalyst
ICU to a hospital ward has been followed by the TRAMS
for the project moving forward.
until decannulation or hospital discharge.
During the same period, the SLT conducted an audit of
The ICU consultants report that they feel safer discharging
all patients discharged from ICU to hospital wards over
patients to the ward, knowing that they will be well cared
a two year period. The audit reflected the slow decision
for. This increases flow through ICU, increasing capacity
making that clinicians had noticed, the lack of consistency
for admissions. Also, Allied Health staff has observed that
24
decannulations are happening quicker and decision making
removed. Over the course of a few weeks the TRAMS team
about tracheostomy weaning and decannulation is more
implemented an aggressive weaning plan and the woman
transparent and collaborative. Ward patients have clearly
was decannulated before discharge from hospital. Removal
documented plans facilitating more consistent care.
of the tracheostomy meant the young woman was able to return home to the care of her family rather than a facility.
The following patient examples demonstrate the benefit
These case examples demonstrate that the TRAMS has
of TRAMS. The first patient, a 50yr old woman, was due
provided a safer environment for this group of vulnerable
for a tracheostomy change after 30 days. As per the
patients and provided support to ward staff when dealing
TRAMS policy, the ICU doctor performed the change with
with an often unfamiliar situation. There have been no
assistance from other TRAMS members. On removing the
unplanned readmissions due to tracheostomy related
old tube some granulation tissue was disturbed and the
issues and no tracheostomy related deaths or near misses.
patient started to bleed quite heavily. This complication was
Quicker, safer decannulation is better for the patient, can
completely unexpected and the patient required the expert
reduce bed days and reduces cost of care.
care that the ICU Doctor and TRAMS team initiated and urgent input from ENT to stop the bleeding. Previously, this
The TRAMS is now well embedded in clinical practice.
incident could have escalated to a point where the patient
In the future we would like to role the service out to the
deteriorated and collapsed resulting in serious harm. The
community and increase our role in education. Ideally, we
presence of expert help ensured that the patient received
could provide consultation and education as needed to
the appropriate care in a timely fashion.
practitioners throughout our region.
The second patient was a young woman with a severe brain
TRAMS succeeded because of the hard work and
injury following a car accident. At the time of her accident
dedication of a range of professionals. In particular we
she had a very low cognitive function and a tracheostomy
would like to acknowledge the following team members:
was placed to assist with breathing and clearance of
•
Thomas Andrews, ICU Clinical Nurse Specialist
secretions. She was discharged to a brain injury facility with
•
Dr. Alex Psirides, Intensivist
her tracheostomy in place and the family was told it would
•
Naomi Seow, SLT
likely be permanent. Six months after her accident she was
•
Dr. Shawn Sturland, Intensivist
re-admitted to hospital with feeding tube complications.
•
Jenny Hill, Patient at Risk (PAR) CNS
The SLT noted her cognitive function had improved slightly and she consulted the TRAMS team. The young woman’s family was very keen to have the tracheostomy
25 Doctors observing a patient in Wellington Hospital
Doctors observing a patient in Wellington Hospital
26
â&#x20AC;&#x153;
The ICU consultants report that they feel safer discharging patients to the ward, knowing that they will be well cared for.
27
â&#x20AC;?
Occupational Therapy Role on the Acute Orthopaedic Ward Capital and Coast District Health Board Article by Jess Thompson
A
cross New Zealand hospitals, the Occupational
This, therefore, led to three themes for process
Therapist (OT) role on the Orthopaedic ward is
improvements: 1. Utilisation of Therapy Assistant role
well established with a significant resourcing of occupational therapy time being dedicated
• Tasks appropriate for delegation to a suitably trained
to elective (mainly hip and knee replacements) and trauma
Therapy Assistant (TA) were identified in consultation
patients.
with the OT Professional Leader. • The TA’s competencies were developed further and the
There have been thoughts amongst many Occupational
TA was then trained in the required skills.
Therapists in the acute setting that this current provision
• Guidelines were developed regarding the TA role on the
of care does not need to be delivered by a trained
orthopaedic ward.
Occupational Therapist, though while this thinking has been 2. Occupational Therapist’s role
ongoing changes in practice have not been evident.
• Education was provided to the orthopaedic In line with this thinking, the new senior Orthopaedic
multidisciplinary team regarding clarification of
Occupational Therapist at Capital & Coast District Health
essential OT input & TA use with this client group.
Board (CCDHB) felt that overprovision of OT input was
• Development of a clinical care pathway for OT and TA
embedded in ward processes. There were expectations on
involvement post hip and knee surgery.
the orthopaedic ward for daily OT input with all patients and
• Development & implementation of a specific
there was little defined or regular utilisation of the Therapy
assessment form targeting single intervention patients.
Assistant (TA) on the Orthopaedic ward. As a result of this 3. Ward processes & resources
and through the statistical review of health roundtable data (hospital data collated from a range of Australian &
• Created new working processes and resources in
NZ hospitals) it showed that CCDHB was providing above
order to increase the efficiency of OT input provided
average input to the Orthopaedic Diagnostic Read Codes.
on the Orthopaedic wards, both to trauma and elective
It was identified that by meeting average input significant
diagnostic read groups.
therapist time could be saved.
28
Occupational therapist showing a range of equipment made to help patients
29
Occupational therapist showing a range of equipment made to help patients.
30
Firstly, a review of OT and TA statistics from January – April 2012 (prior to implementation) with a comparison made to November – February 2013 (after implementation). This demonstrated TA input had increased with all DRG categories, though most significantly with hip conditions, while OT input with all DRG categories had decreased and overall total time had decreased. This change occurred while the quality of care was not impacted negatively. Secondly review of OT clinical requirements December – March 2013 This showed the OT consistently finished their caseload after six hours vs. eight hours (as per before implementation) This change aligned with the Institute for Healthcare Improvement (IHI) Triple Aim principles as identified below: • Improving the experience of patient care, including quality and satisfaction. • Clear and transparent processes were developed for patient assessment and treatment, which were provided through efficient & timely use of resources with intervention targeted at patient need. This was consistent with evidence based practice and was provided through quality assessment and treatment. This was evidenced through; • Utilisation of the TA role where OT was not required allowing OT resources to be redirected to patients requiring OT skills.Development of clear guidelines for staff around expected input with specific patient groups ensuring consistent input from OT team and ensuring appropriate care is provided. • Increased time for senior OT to mentor and up skill other team members, leading to improved patient care. Reducing the per capita cost of health care: • Reduction in resources from OT – evident by OT seeing less Orthopaedic patients and the time taken to see patients reducing, while the provision of quality care has been retained by the use of TAs.
31
Enhanced Recovery After Surgery (ERAS) in Orthopaedics Taranaki District Health Board Article by Greg Sheffield
A
Taranaki project aimed at helping patients recover
help identify patients with comorbidities (e.g. anaemia,
more quickly after knee and hip surgery has proven
poorly controlled diabetes, hypo/hypertension) and
a great success, with the average length of stay
instigate timely and appropriate onward referral
reduced by 30 percent. Enhanced recovery after
• Consistent education regarding alcohol and smoking
surgery (ERAS) is designed to prepare patients
cessation
for, and minimise the total impact of, surgery by helping
• An Allied Health screening tool. This helped to identify
them to recover more quickly. It does this by applying an
patients that would benefit from allied health input such
evidenced-based approach to care. ERAS aims to optimise
as dietician input to manage malnutrition, physiotherapy
patient outcomes by the aggregation of marginal gains.
to regain function, or occupational therapy to advise on and provide home equipment
A working group was set up in July 2012 to look at the
• A RAPT (risk assessment and predictor tool) score – this
potential for ERAS principles to be applied to patients
is a tool that scores patients social factors to predict
undergoing primary total hip replacements (THR) and total
whether they are likely to have an extended length of
knee replacements (TKR) at Taranaki District Health Board
stay. This was used to focus and prepare services for
(TDHB).
those patients that were most likely to benefit.
An initial review of our pathways identified several factors to
• A comprehensive, anaesthetist-led, pre-operative
work on:
assessment aimed to provide clear and consistent
• Elective THR and TKR were our single biggest pathway
information to the patient to help reduce any anxiety by
• Our average length of stay was 6.72 days
involving them in the decision making processes
• Multiple pathways for different orthopaedic surgeons
• A pre-operative education class, for patients, two weeks
• The lack of a structured joint replacement pathway
prior to surgery – detailing the patient journey through
across all specialties
hospital and once back at home following surgery
• Obtaining a better understanding of inpatient costs in
• Providing a carbohydrate drink two hours before
an increasingly challenging fiscal climate
surgery to minimise dehydration and the stress
• Most importantly, improving patient experience and
response of surgery.
clinical outcomes Intra-operative Having identified our challenges, the working group set
• Default regional anaesthesia +/- sedation
about reviewing the latest literature and evidence from
• Standardised analgesic pathway
within New Zealand and overseas. As a result of this, we
• Minimising blood loss through the use of tranexamic
made a series of changes to our patient pathways – through
acid and avoidance of surgical drains
pre-operative, intra-operative and post-operative phases.
• Standardised prosthesis Post-operative
The key changes introduced were: Pre-operative
• Promotion of patient independence throughout the
• A nurse-led triage service five months prior to surgery.
whole process
This included robust screening and laboratory testing to
• Early oral hydration and nutrition
32
• Regular oral analgesia
Greg Sheffield, the ERAS project manager, stated the most
• Early removal of catheters and IV lines
important outcomes were, “bringing in a patient education
• Planned early and regular physiotherapy
class about two weeks before the patient comes in. We
• Early return home
talk them through exactly what’s going to happen – what’s
• Strong ties to on-going rehabilitation in the community
going to happen in theatre, what’s going to happen after surgery, what to do before surgery, how to prepare, how
Managerial
to prepare their home for after surgery so they’ve got
• A standardised multidisciplinary protocol
everything ready. It’s particularly important to make sure the
• Re-developed critical pathway documents
home is ready.”
• New patient information booklets • Pre-printed medication charts
“Patients felt fully informed and well prepared for all aspects
• Analgesic pathway posters
of their surgery.”
The changes were trialled with one orthopaedic surgeon in
“We used to be the worst DHB in New Zealand for our
January 2013, following positive feedback and improved
length of stay. I’m confident we will be one of the better
outcomes for the patients the changes were then rolled out
performing DHBs now.”
to the remaining orthopaedic departments in August 2013. Having implemented this raft of changes the overarching
“The project is a great example of how well multidisciplinary
achievements were:
teams can work alongside one another and most specifically
• High degrees of patient satisfaction
the importance of the many allied health, scientific and
• A reduced average length of stay from 6.72 days to
technical roles within these teams.”
4.30 days In October 2013, a national collaborative for Orthopaedic
• The average cost per patient reduced by 12%, a saving
ERAS was launched by the New Zealand Ministry of Health,
of approximately $2,500 per patient • Lower re-admission and complication rates
with a view to rolling out ERAS nationally by January 2015.
• Improved DOSA (day of surgery admission) rates
We look forward to continuing our work on this project, and hope to achieve further successes yet.
33
Greg Sheffield, ERAS project manager
Pharmacist Prescriber Counties Manukau District Health Board Article by Gemma Stanbridge
F
ollowing changes to the law and the initial
reasoning skills. Over these hours the pharmacist and
innovation pilot for pharmacist prescribing in
medical practitioner supervisor collect evidence to show
New Zealand, Middlemore Pharmacy Services
the Pharmacist has achieved the competencies required to
manager Sanjoy Nand initiated the feasibility
collaboratively prescribe within their specialist area. After
of pharmacists prescribing drugs in particular areas of
the supervisor has signed off on the supervised hours and
competence at Middlemore Hospital.
the pharmacist has completed the assessments required by the postgraduate course, the pharmacist may apply
Changes to the Medicines Act 1981 and the Misuse of
to register as a pharmacist prescriber with the Pharmacy
Drugs Act 1975 allow clinical pharmacists who have
Council of New Zealand.
demonstrated competence to prescribe medicines in a specific area. The feasibility project focused on pharmacy
The monetary cost of training to be a pharmacist prescriber
prescribing in a hospital and outpatient setting and was run
is around $4000 for a postgraduate qualification. However,
in 2013.
most of the cost is in time at the hospital for the supervision requirement hours, but this can be offset by the benefits a
“The first cohort in 2012 were the pioneers. That pilot
pharmacist prescriber makes to the system and patient care.
was run to enable the decision of whether it was a good
Ms Kam said postgraduate study is encouraged, but is
idea or not,” Mr Nand said. A clinical pharmacist training
not an easy undertaking, but the qualification is a point of
to be a pharmacist prescriber chooses a specific area to
difference that shows a pharmacist possesses competency
demonstrate prescribing competence in.
in a certain area.
Middlemore Renal Services clinical pharmacist Angela
“It shows you are competent and can provide something
Kam took on the opportunity to train as the first pharmacist
above and beyond,” she says.
prescriber at Counties Manukau Health. “It makes the job a lot more varied; there are more “Choosing to work in a certain specialty does not
opportunities, more options.”
limit opportunities for pharmacists, ,” Ms Kam says. “Pharmacists are still able to branch out and expand their
The innovation pilot saw 14 clinical pharmacists nationwide
knowledge and skills even further.”
complete the one-year Postgraduate Certificate in Pharmacy Prescribing at either the University of Auckland or the
Pharmacists interested in upgrading their skills are required
University of Otago in the first year (2012).
to find a dedicated medical practitioner who will supervise them for 150 hours. The supervised hours include patient
Mr Nand said traditionally the pharmacists work as advisors
consultations, and interactions to demonstrate therapeutic
while doctors do most of the prescribing. Now pharmacist
34
prescribers, with the level of experience and knowledge
Ms Kam says she works in a multidisciplinary and
along with the postgraduate certificate in prescribing, can
collaborative environment and part of her training
also prescribe, but only in their area of competence.
includes observing consultant clinics. She works with the doctors and nurses at the hospital to develop lines of
Mr Nand said pharmacist prescribing is important because
communication, following up on blood tests, and
it makes for efficient decision making especially when
providing advice.
resources are stretched. Ms Kam said the role of a pharmacist is traditionally “Doctors and pharmacists can work in a better collaborative
thought of as counting pills. “It’s totally different now. The
environment with trust and understanding. There is better
opportunities for career progression makes pharmacy a
discussion and agreement, and better, more informed,
more attractive option for students. The programme sets the
decisions can be made which is always better for the
way for junior pharmacists,” she said. Mr Nand agrees.
patients,” he says. “There is better career progression, autonomy, increased job Ms Kam follows up on renal patients on a weekly or
satisfaction and remuneration, and it enables competition in
fortnightly basis in an outpatient setting, monitoring the
the global market,” he says.
effects and benefits of medication decisions and developing a relationship with her clients.
Angela Kam - Pharmacist Prescriber
35
Paediatric Multimedia Project Canterbury District Health Board Article by Kate Parker
iPod in use
Kate Parker, creator of multimedia project
R
adiotherapy is an important treatment used to help cancer
iPods. This has enabled the department to buy iPods and an extensive
patients of all ages. It is a targeted treatment which requires a
iTunes library, so children have a large variety of movies to choose from.
high level of precision and because of this patients must stay
The use of this multimedia has made treatment for many children more
extremely still during treatment. A full treatment course can
accurate and less stressful.
be up to 30 visits over six weeks. They can also last for up to
half an hour per visit so this can be a very difficult. Now imagine asking an
The second part of the multimedia project was the development of
eight year old to do this.
treatment movies for the child. This is a documented journey of the childâ&#x20AC;&#x2122;s treatment but is done in a fun way. They can be used by the child
If a child in unable to stay still for treatment they require a general
to remember what happened to them later in life or as a teaching tool for
anaesthetic. This can be very distressing for the child and their family not
friends and family. These movies were made possible by donations of a
to mention extremely resource intensive. The average cost of a general
MacBook Pro and editing software from the Child Cancer Foundation.
anaesthetic is $1000 per procedure.
Post-production editing is currently being done for free by a kind graphic designer. Since the start of this project ten treatment movies have been
A paediatric team was established in order to investigate ways to make
made for the children.
radiation treatment easier and less traumatic for children in Christchurch Hospital. The aim was to make treatment as enjoyable as possible and
The department has had a lot of positive feedback from patients, their
be remembered as a positive experience. Visiting the Peter MacCallum
family and other staff involved in the wider treatment of the child. The use
Cancer Centre in Australia and liaising with other centres in the UK lead to
of multimedia in this department could possibly be used as a template for
establishing the multimedia project. This involves using multimedia on an
other departments in the hospital. We are also looking at extending the
iPod as a distraction tool for children.
project to be used for young adults. Cancer diagnosis and treatment can be a stressful time for all involved and the oncology department aims to
In order to do this, a special viewing mount had to be constructed that
make this experience as pleasant as possible for everyone involved.
attached to the treatment couch. It needed to be able to be positioned out of the way of the radiation beam but allow the child to watch it at the same time. The team in the Medical Physics Department were able to develop a state of the art mount using an iPhone car-kit, a stereoscopic arm used for patients in wheelchairs and an industrial clamp gentle enough to not damage the carbon fibre treatment bed. Over $3000 of donations has been raised through staff fundraising events and from individual donations in the form of iTunes vouchers and pre-loved
37
38
Radiation Machine
â&#x20AC;&#x153;
If a child in unable to stay still for treatment they require a general anaesthetic. This can be very distressing for the child and their family not to mention extremely resource intensive.
â&#x20AC;?
39
Education Focus
Allied Health Technical and Scientific Educator Sonography Training
41
Allied Health Technical and Scientific Educator Capital and Coast District Health Board Article by Suzanne Stubbs
A
llied Health, Technical & Scientific (AHT&S)
in a sub-regional model, however it is recognized that there
encompasses over 30 different professions.
are instances where a DHB has a training requirement that
Although the educator role is an established
others do not have, therefore flexibility is key. An increase
role within the nursing and midwifery
in access to learning and development for the AHT&S
professions it is a new role for AHT&S, and
professionals enables workforce development and supports
this is the first of its kind in New Zealand.
provision of a quality service for patients.
The joint funding and support for this role as a three
Key areas identified for the role to initially focus on were:
DHB position is also one of the first sub-regional roles
• Objective Setting & Portfolio Development Training
within AHT&S.
• Clinical Goal Setting Training • Clinical Effectiveness Training (i.e. Change
As a result of more joined up working throughout the
Management, Clinical Audit, Research Skills, Project
AHT&S professions and within management structures of
Management)
the three DHBs it was identified that there were a number of commonalities within the workforce with regards to their
This has since progressed to include the following:
learning needs. There are generic and shared needs within
• NZQA Training for Allied Health (Dental & Rehab) Assistants
professions, across sites and also common learning needs
• Coordination of the AHT&S Seminar Series (in
across the AHT&S professions.
conjunction with the University of Otago) • Career and Salary Progression (CASP) training
Prior to the development of the AHT&S educator role, training and education was managed by individual teams and managers. This led to fragmented and inconsistent provision of training, duplication of work or more
“An increase in access to learning and development for the AHT&S professionals enables workforce development and supports provision of a quality service for patients.”
commonly no training or
• Analysis of the need for Preceptor training • Analysis of Supervision training across all three DHBs and developing a sub-regional training framework An example of one of the training initiatives led by the Allied Health,
development opportunities for some professional groups or
Technical and Scientific Educator is the roll out of the allied
in certain areas of learning need.
and public health CASP training.
The mandate of the AHT&S educator role is to coordinate,
This training package was developed to support a regional
support and evaluate core training required by the AHT&S
project, which aimed to align the way the CASP process
professional groups and the DHBs. Where a three DHB
was delivered across DHBs and services.
approach can be taken training is developed and delivered
42
Suzanne Stubbs
43
The need for training of staff and managers on the new
we are in a strong position to foster and grow this through
process was identified by the project group; this was then
the educator role, which is focussed on educational
passed on to the educator who was able to work with the
opportunities across professional groups.
project team to develop a training package. This included trainer notes and presentation, learning resources and
Christine King, Associate Director, Allied Health,
an evaluation plan which could be rolled out across the
Technical & Scientific, CCDHB
region using a train the trainer approach. The evaluations were designed to evaluate the new process as well as the As an Allied Health Professional Leader and Manager I have
training, so are able to feedback into the project team.
found the establishment of the Allied Health educator role very beneficial.
Using such an approach ensures consistency of messaging and saved duplication of work for each DHB developing
Prior to the role being in place the emphasis was on managers
individual training.
to provide training on the CASP framework and processes. Feedback from those involved The Allied Health, Technical & Scientific Educator role has
It’s my observation that the development and
been pivotal in the central region roll out of consistent
implementation of training for CASP as well as therapy
processes for CASP.
assistant training and supervision training of which has been led by the Allied Health Educator has provided support to
The educator role has supported the working party by putting
leaders and managers that has supported ongoing education
the newly developed ‘consistent’ processes into action
and development of their staff.
through the development of our new look training, of which is Sue Doesburg, 2DHB Professional Leader –
being delivered in line with educational delivery best practice.
Physiotherapy, Hutt Valley and Wairarapa DHBs This role provides the expertise in the delivery of education and evaluation specific to our professions that we have not
The AHT&S educator and the sub-regional AH leadership
had access to or support for previously and it is evident
have an on-going shared dialogue regarding current and
with this role now in place that we were previously missing
future projects. This ensures alignment with the strategic
access to a very valuable role.
direction of the AHT&S leadership, DHBs goals and ensures accountability.
The educator role has also reinforced the many aspects of training that are consistent and can be shared across
This role has ready access to experts in the learning and
different professions and in this period where inter-
development field, an education technology advisor and
professional training is becoming increasingly recognised
media developer, as well as administrative support.
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Workbook to help students
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Sonography Training Counties Manukau District Health Board Article by Gemma Stanbridge
T
he Counties Manukau and other Northern Region
The Sonographer Workforce Project began in September
DHBs (Northland DHB, Waitemata DHB, Auckland
2012 and involved the Northern Region District Health
DHB) have launched a new collaboration with the
Boards, private practices, and the University of Auckland
private and university sectors to train sonographers.
who have recently established the Postgraduate Diploma in Health Science in Ultrasound (PGDipHSc).
At present there is a sonographer shortage. This affects not only the workload and morale of many who work in under-
Initiated by Mr Hewitt, and the Northern Regional Radiology
staffed ultrasound departments but also patients on waiting
Network, the project brought these groups together because
lists and hospital bed space. The most significant person
the long-standing problem of a qualified sonographer
affected by this is the patient.
shortage affects most of the wider Auckland region.
Middlemore Radiology Services manager Paul Hewitt said
Middlemore Ultrasound team leader Ms Azile Hooper said
wait times for an ultrasound scan, for patients in hospital,
there were plenty of people wanting to learn ultrasound, but
can be up to three days when departments were under-
there was a bottle neck in clinical placements.
staffed, compared to same-day scanning when fully staffed. Currently the New Zealand radiology professional body says There can be lengthy waiting times for patients needing
a trainee must complete 2000 supervised hours to become
routine ultrasound scans, if referred from a clinic or from
a qualified sonographer.
the family doctor. Some smaller hospitals have to fly sonographers in on weekends.
“You cannot learn ultrasound by watching someone scan, you need to do it yourself. It’s my hand on the student’s
By the time you get to the scan you could be in a clinically
hand showing them how to work the probe.”
worse situation, Mr Hewitt said. “Traditionally we’ve only had three students at one time,” Adding to this is that demand for ultrasound has increased
Ms Hooper said.
substantially over the years and sonographers now perform a much broader range of examinations.
Providing this supervision for sonographer trainees, is a huge commitment for any healthcare provider as the institution’s
Ms Hooper says, “We used to only do abdominal, pelvic,
workload has to be slowed down to allow the trainees hands-
obstetric and ‘small parts’ such as thyroid and scrotum
on training time which in turn affects patient waiting times.
scans. Now we scan tendons, muscles, blood vessels, heart and eyes.”
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The Sonography workforce project is looking at alternative
Ms Hooper said this collaboration in itself should generate
training and clinical placement models in a unified way across
more clinical placements for trainees in both the public and
the public and private sector. It was recognised being creative
private sector. This part of the project has progressed well
was important, said Ms Hooper, and that doing the same as
and looks promising to start in 2014.
they had in the past, was not an option. The project’s overall aim is to gain an accurate assessment The project group decided two goals needed to be pursued.
of sonographers needing to be trained and not to have a
The first was an investigation of the options to generate
‘knee-jerk’ reaction to sonographer shortages. With the next
additional resourced, clinical placements in the region. This
step being to collaboratively increase the number of trainee
investigation produced detailed data for the region on the
positions for the region and nation, as well as having a
number of patients scanned, the growing and changing
collaborative approach to the training.
population demographic, and the anticipated number of sonographers required for the current and future population.
Mr Hewitt said the project had been welcomed and it was
The second goal was to investigate the feasibility of
successful in bringing both public and private radiology
implementing a 12 to 14 week intensive training course for
providers together, which is a great outcome.
trainee sonographers.
One of the challenges, Mr Hewitt notes, is changing the length of time to qualify. “It’s a journey of changing hearts
This would involve a collaboration of both public and private
and minds.”
sectors along with Auckland University. This course was a significant development as it took the very intensive oneon-one initial training away from the ultrasound providers so that patient waiting times would not be adversely affected by taking on new trainees.
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